Summary of HIQR Information Collection Forms: Updates for the

Summary of HIQR Information Collection Forms: Updates for the

FY 2018 IPPS Final Rule

Form	Notes on Updates
Hospital Inpatient Quality Reporting Notice of Participation	No updates/changes to previously submitted form. Form still in use.
Hospital Inpatient Quality Reporting (IQR) Program Data Accuracy and Completeness Acknowledgement (DACA)	Form resubmitted to update applicable program year.
Hospital Compare Request for Withholding Data from Public Reporting Form	Form resubmitted to update preview period dates, include the names of all applicable quality reporting and pay-for-performance programs with updates to submission information (which includes providing the submission deadline for claims-based measures), and to add/remove measures for the upcoming preview period and Hospital Compare release.
Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) Quality Reporting Programs Measure Exception Form for PC, ED, and HAI Data Submission	No updates/changes to previously submitted form. Form still in use.
CMS Quality Reporting Program APU Reconsideration Request Form	Form resubmitted to add a signature line for the designated provider personnel’s signature.
Hospital Inpatient Quality Reporting (IQR) Program Validation Educational Review Form	Form newly included with this PRA package.
Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form	No updates/changes to previously submitted form. Form still in use.
Hospital Value-Based Purchasing (VBP) Program Appeal Request Form	No updates/changes to previously submitted form. Form still in use.
Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form	No updates/changes to previously submitted form. Form still in use.
Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program Extraordinary Circumstances Exceptions (ECE) Request Form	Form being resubmitted to align terminology with other quality reporting and pay-for-performance programs that have policies to provide exceptions from program requirements to facilities that have experienced extraordinary circumstances.
CMS Hospital IQR Program Validation Review for Reconsideration Request Form	No updates/changes to previously submitted form. Form still in use.
Validation Templates for CLABSI, CAUTI, MRSA, and CDI measures	Templates resubmitted to reflect the annual changes in fiscal year and beginning reporting quarter, as well as new CDC pathogen lists, with each new selection of hospitals for validation.

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